Based on interview and document review the facility failed to follow facility policy to identify allegations of verbal abuse and threats of involuntary seclusion reported through grievances, that were made about 2 staff (registered nurse (RN)-A) and licensed practical nurse (LPN)-A) involving 6 of 40 residents (R27, R30, R43, R13, R44 and R100). In addition, the facility also failed to perform timely and thorough investigations, report allegations to the SA, and immediately suspend RN-A and LPN-A per policy pending the investigations.Findings include: Review of the grievances submitted from 2025 and 2026 grievances identified the following grievances:On 8/19/25, a grievance was filed regarding R100 by the former director of nursing (DON)-A. …
F607 citations in Minnesota
Abuse-prevention policies · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Minnesota cites F607 less often than its own record predicts
0.53 times the national share — cited less often here than elsewhere.
Of every deficiency written in Minnesota in 2025, this is the portion that was F607.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Minnesota surveyors wrote
F607 findings written in Minnesota, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interview and document review the facility failed to develop policies and procedures for when to report a suspected crime to law enforcement. This had the potential to affect all residents residing in the facility.Findings include:The facility Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy dated 11/24, identified local law enforcement would be notified of any reasonable suspicion of a crime against a resident in the facility. the policy included reporting a suspected crime and/or alleged sexual abuse must be immediately reported to local law enforcement to be investigated; however, lacked further examples of crimes that should be reported.During interview on 7/30/25 at 4:19 p.m., the director of nursing (DON) stated the facility abuse policy… …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 0.39% | 0.52× |
| 2024 | 0.32% | 0.42× |
| 2025 | 0.35% | 0.53× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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